Provider Demographics
NPI:1629777081
Name:TIDWELL, ANNA JANE
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:JANE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6486 S 1655 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2527
Mailing Address - Country:US
Mailing Address - Phone:801-680-4097
Mailing Address - Fax:
Practice Address - Street 1:6486 S 1655 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2527
Practice Address - Country:US
Practice Address - Phone:801-680-4097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program